A Reflux Revelation

Gastroesophageal Reflux Disease (GERD)

  • Sixty percent of the adult population will experience some type of gastroesophageal reflux disease (GERD) within a 12 month period and 20 to 30 percent will have weekly symptoms. 1
  • Approximately seven million people in the United States have some symptoms of GERD. 2
  • In 2004, approximately 20 percent of the United States population reported reflux symptoms that occurred at least weekly. 3
  • Primary or secondary GERD diagnosis increased by an unprecedented 216 percent or from a total of 995,402 individuals diagnosed in 1998 to 3,141,965 in 2005. 4
  • Children with GERD symptoms who were hospitalized with a primary GERD diagnosis increased by 42 percent in infants and 84 percent in children between the ages of two and 17. 5
  • There are approximately 64.6 million prescriptions written for GERD medications in the United States on an annual basis. 6
  • It is estimated that worldwide, approximately 5 to 7 percent of the total population has symptoms of GERD, which is most commonly reported as heartburn that occurs on a daily or frequent basis. 7

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Ask the average person what they think causes heartburn, and they will probably tell you it’s stomach acid. While largely unproven, this conclusion has been widely accepted and likely derived from the ‘burning’ sensation, and success with treatment using proton pump inhibiting (PPI) medications like Nexium, Prevacid, and Prilosec. PPI medications reduce gastric acid by blocking the gastric pump of stomach parietal cells, so one would naturally assume the reduction in acid is to credit for the relief in our associated ‘burning’ GERD symptoms.

However, what most people don’t realize, is that PPI medications can also serve as powerful anti-inflammatories. 8 In fact, a published study review concluded that PPI medications potentially have beneficial effects in any number of inflammatory diseases, gastrointestinal or extra-intestinal, in which acid has no role, and a positive clinical response to PPIs should not be interpreted as proof of an underlying acid-peptic disorder. 9 The review goes on to suggest that patients may be mistaking their symptom improvement on PPI medications as acid reduction, when in fact it is a reduction of inflammation within their gastrointestinal tract. 10

And there is further compelling evidence bringing into question the presumed etiology of GERD, from a recent study done on 12 patients being treated with PPI’s for their reflux esophagitis. 11The study concludes that the damage done to each patient’s esophagus was not caused by stomach acid, but by an inflammatory immune response. 12

So, let’s review: For some of us, the pain we know as ‘heartburn’ potentially has nothing to do with the gastric acids produced by the stomach, and instead is the result of immune inflammation and aggravation within the upper gastrointestinal tract/esophagus. PPI medications are anti-inflammatories so they are potentially reducing the inflammation, thereby eliminating the associated pain. Sounds like the perfect treatment solution, right?

That is, until you consider the risk of side effects – especially with long term use of PPI medications. Adequate stomach acid is a necessary and relevant part of the metabolic process, and there are adverse consequences to habitually reducing/eliminating it. PPI use has been linked to the predisposal of certain infectious diseases, dementia, kidney disease, heart attacks, stroke, vitamin deficiencies, bone fractures, and gut dysbiosis – just to name a few. 13 14

But there is an alternative option: Determine what is triggering the immune inflammation in your GI tract and eliminate it. It will cost you nothing, except some time and effort, there is no risk of any adverse side effects, and you may end up eliminating other cryptic inflammatory symptoms you did not even realize were associated to the exposure.

My advice? Start by removing some of the top allergen offenders from your diet one at a time, and see if you notice a difference in your GERD symptoms. And start paying attention to what you’ve been exposed to recently when your symptoms are at their worst. Did you suffer with heartburn all night after eating a bowl of ice cream? That should raise dairy up to the top of your suspect list. With time and practice, your allergen detective skills will improve, but try to keep it simple initially. And bear in mind that there may be multiple allergens contributing to your symptoms, and the sources may potentially include environmental triggers (lotions, detergents, soaps, pollen, cat dander, etc.), in addition to food or medication.

InfantGERDThere is another chapter to this story we have not yet explored: Infant gastrointestinal reflux disease, and this is where things become slightly more complicated. There is no question that the use of PPI medications in infants and young children is skyrocketing. One large study of about 1 million infants revealed prescriptions for one of the PPIs, made in a child-friendly liquid, rose 16-fold between 1999 and 2004. In addition, there was an overall 7-fold increase in prescriptions for PPIs for infants, and of the prescriptions written for children under 1, about half of those were for infants younger than 4 months of age. 15

But – what exactly are we treating our infants for, with PPI medications? The clinical symptoms associated with infant GERD (depending on who you ask), can range from excessive/inconsolable crying, frequent vomiting/spit up, trouble latching and swallowing, loss of appetite, failure to thrive, diarrhea, blood/mucous in stool, gas, constipation, etc. Those hardly seem like a list of symptoms that can all be attributed to acid ‘burns’ resulting from regurgitation, and not all babies with GERD symptoms regurgitate (a condition known as ‘silent reflux’).

Not surprisingly, there is mounting evidence demonstrating that a wide range of gastrointestinal pain, motility and oral motor dysfunction symptoms, including those listed above, can all be attributed to various stages of gastrointestinal immune aggravation and inflammation. 16 17 18 19 20 21

In addition, there is plenty of evidence to suggest that identifying and eliminating food and environmental sensitivities is as effective as medications for treating gastrointestinal immune inflammation symptoms in children (with one particular study indicating cow’s dairy, soy, and wheat at the top of the list of offenders). 22 23 24

A few pointers regarding identifying and eliminating allergens in infants and young children.

  • You may find that most pediatricians will focus on cow dairy as the sole problematic component, and recommend a partially hydrolyzed (hypoallergenic) or fully hydrolyzed (super hypoallergenic/elemental) infant formula. However, nearly all powder infant formulas use corn as a sweetener so you may inadvertently end up replacing one potential allergen with another.
  • Given the extensive list of ingredients on the average can of infant formula these days, you will probably find a trial and error elimination of allergens from a breastfeeding mother’s diet to be easier and more accurate. (Not to mention, you get the added benefit of the immune modulating properties inherently found in breastmilk to potentially help battle the underlying hyper-immune conditions). 25 26 27
  • Research has demonstrated that gastrointestinal immune inflammation and activation can contribute to dysphagia (trouble swallowing), neuro-muscular dysfunction, intestinal motor abnormalities, and GI dysmotility. 28 29 Consequently, you may find that seemingly unrelated issues with latching, nursing, and the bowels may magically improve and/or resolve once the underlying immune inflammation is addressed.
  • Infant and young children’s metabolism is much faster than an adult’s, so you will typically see clinical improvement quickly once you identify and removing the offending allergen(s).

Allergen Sensitivity

  • According to the American Academy of Allergy, Asthma & Immunology, sensitization rates to one or more common allergens among school aged children are currently approaching 40%-50% worldwide.
  • One in five people in the U.S. currently have allergy or asthma symptoms.
  • 55% of Americans test positive to one or more allergens.

But for all our efforts to subdue the villainous stomach acid, the statistics are not getting any better. But perhaps that’s because we have been chasing the wrong villain. We know that This study, published just last month, strongly suggests that acid is not the underlying cause for the ‘burn’ in heartburn. Instead, an inflammatory immune response is. That’s right – your undiscovered dairy, gluten, corn, egg, or soy sensitivity may be entirely to blame for those pesky GERD symptoms you have been popping Nexium to treat. 30

But that does bring up an interesting point, if acid is not causing the burn then why are PPI (Proton Pump Inhibitor) medications like Nexium, Prevacid, and Prilosec so effective at treating the symptoms? We know that PPI’s reduce gastric acid by blocking the gastric pump of stomach parietal cells, so we would naturally assume the reduction in acid is to credit for the relief in our associated ‘burning’ GERD symptoms. However, it turns out that PPI medications have another, more relevant function in this scenario.

Recent research has demonstrated that PPIs also serve as powerful anti-inflammatories, independent from their function of blocking acid production. A published study review concluded PPI medications potentially have beneficial effects in any number of inflammatory diseases, gastrointestinal or extra-intestinal, in which acid has no role, and a positive clinical response to PPIs should not be interpreted as proof of an underlying acid-peptic disorder. 31

Notes:

  1. Gastroesophageal Reflux Disease (GERD) Hospitalizations in 1998 and 2005 – HCUP-US Home Page. Retrieved March 5, 2012, from: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb44.jsp
  2. Gastroesophageal Reflux Disease (GERD). (n.d.). Office of Medical Informatics – College of Medicine – University of Florida. Retrieved March 5, 2012, from: http://medinfo.ufl.edu/~gec/coa1/gerdfaq.html
  3. Digestive Diseases Statistics for the United States – National Digestive Diseases Information Clearninghouse. (n.d.). Home – National Digestive Diseases Information Clearninghouse. Retrieved March 5, 2012, from: http://digestive.niddk.nih.gov/statistics/statistics.aspx#specific
  4. Gastroesophageal Reflux Disease (GERD) Hospitalizations in 1998 and 2005 – HCUP-US Home Page. Retrieved March 5, 2012, from: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb44.jsp
  5. Gastroesophageal Reflux Disease (GERD) Hospitalizations in 1998 and 2005 – HCUP-US Home Page. Retrieved March 5, 2012, from: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb44.jsp
  6. Gastroesophageal Reflux Disease (GERD) Hospitalizations in 1998 and 2005 – HCUP-US Home Page. Retrieved March 5, 2012, from: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb44.jsp
  7. GERD Costs America Nearly $2 Billion Each Week in Lost Productivity – International Foundation for Functional Gastrointenstinal Disorders. Retrieved March 5, 2012, from: http://www.iffgd.org/site/news-events/press-releases/2005-1125-gerd-costs
  8. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3035917
  9. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3035917
  10. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3035917
  11. http://jama.jamanetwork.com/article.aspx?articleid=2521970
  12. http://jama.jamanetwork.com/article.aspx?articleid=2521970
  13. http://www.webmd.com/heartburn-gerd/news/20160608/proton-pump-inhibitor-health-risks
  14. http://www.webmd.com/heartburn-gerd/news/20141125/could-popular-heartburn-drugs-upset-your-good-gut-bugs
  15. http://www.livescience.com/16636-acid-reflux-drugs-overused-babies.html
  16. http://www.ncbi.nlm.nih.gov/pubmed/26022877
  17. http://www.ncbi.nlm.nih.gov/pubmed/17053446
  18. http://www.ncbi.nlm.nih.gov/pubmed/18713339
  19. http://www.ncbi.nlm.nih.gov/pubmed/25808260
  20. http://www.ncbi.nlm.nih.gov/pubmed/25845555
  21. http://www.ncbi.nlm.nih.gov/pubmed/26194403
  22. http://www.ncbi.nlm.nih.gov/pubmed/26022877
  23. http://www.ncbi.nlm.nih.gov/pubmed/25808260
  24. http://www.ncbi.nlm.nih.gov/pubmed/25845555
  25. http://www.ncbi.nlm.nih.gov/pubmed/27183772
  26. http://www.ncbi.nlm.nih.gov/pubmed/20485331
  27. http://www.ncbi.nlm.nih.gov/pubmed/21444329
  28. http://www.ncbi.nlm.nih.gov/pubmed/18713339
  29. http://www.ncbi.nlm.nih.gov/pubmed/26194403
  30. http://www.ncbi.nlm.nih.gov/pubmed/26022877
  31. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3035917

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